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Case of the Month
Clinical Decision Under Constraint
Real-world maritime scenarios designed to sharpen your clinical decision-making at sea. Calm, operational, realistic.
Crushing Chest Pain, 14 Hours From Port
0230h. You are the sole physician on a 2,800-passenger cruise ship in the mid-Atlantic. A 52-year-old male crew member presents with crushing retrosternal chest pain radiating to the left arm, onset 45 minutes ago. Diaphoretic. GCS 15. 12-lead ECG shows ST elevation in V2–V4.
HR 104 • BP 148/92 • SpO2 96% on RA • RR 22 • Temp 36.9°C • NEWS2: 4
PMH: Hypertension (amlodipine 5mg), smoker 20 pack-years. No previous cardiac history. No allergies documented.
Nearest port with PCI capability: 14 hours at full speed. Helicopter range exceeded — nearest SAR base 680nm. Sea state 5 (rough). Satellite connection intermittent. Ship pharmacy: aspirin, clopidogrel, enoxaparin, morphine, GTN, tenecteplase available. No cardiologist onboard. TMAS line operational but 20-minute hold times reported this week.
You are facing a confirmed STEMI with no access to percutaneous coronary intervention for at least 14 hours. Fibrinolysis window is narrowing. The bridge is requesting your medevac recommendation. You have tenecteplase but have never administered it without a cardiologist present. TMAS is on hold.
What do you do? Consider: fibrinolysis risk-benefit, contraindication screening, bridge communication for potential diversion, and your documentation obligations.
Helicopter transfer not feasible. Ship-to-ship transfer considered but sea state prohibitive. Diversion would cost the company an estimated $800K+ and disrupt 2,800 passengers. Your clinical documentation will be reviewed by the company, flag state, and potentially port state authorities.
- Pre-hospital fibrinolysis protocols exist for exactly these resource-limited scenarios
- Document your decision-making process in real time, not retrospectively
- SBAR-M to bridge should include: clinical urgency level, time-sensitivity, and your specific operational request
- A well-documented clinical decision to treat is more defensible than a delayed transfer request
- Tenecteplase is weight-based, single bolus — review dosing before the emergency
Featured Articles
Most Read on The Ship Doctor
In-depth guides on entering maritime medicine, preparing for interviews, and communicating with command teams at sea.
How to Become a Ship Doctor
A complete guide to entering maritime medicine — qualifications, training pathways, certifications, and what the role actually involves when you step onboard.
Read the guide →Ship Doctor Interview Questions
The questions you will actually be asked in a ship doctor interview, with operational context and preparation guidance from real maritime medicine experience.
Read the guide →Cruise Nurse Interview Questions
Interview preparation tailored for nurses entering cruise ship medicine — covering clinical scenarios, shipboard operations and team dynamics at sea.
Read the guide →Bridge Phrases for Maritime Clinicians
Structured communication templates for translating clinical urgency into command language the bridge team understands and can act on immediately.
Read the guide →Hantavirus at Sea and in Remote Environments
Recognition, risk and response for maritime clinicians — a practical overview of hantavirus in shipboard and remote-site settings.
Read the article →STEMI at Sea — When Minutes Matter and PCI Is Hours Away
Managing ST-elevation myocardial infarction at sea. ECG interpretation, thrombolysis decisions, oxygen management and medevac triggers.
Read the article →Stroke at Sea — Recognition, Time Windows and Evacuation Decisions
Time is brain, but time is also distance. FAST assessment, blood pressure management and medevac triggers for maritime clinicians.
Read the article →Sepsis on Cruise Ships — Recognition, Resuscitation and Escalation
Managing sepsis in the ship medical centre when ICU transfer is impossible. NEWS2 triggers, fluid resuscitation and medevac decisions.
Read the article →USPH Inspection Preparation for Ship Medical Teams
How to prepare for USPH Vessel Sanitation Program inspections. Medical centre readiness, documentation and common findings.
Read the guide →Cruise Ship Doctor Salary 2026 — What Ship Doctors Really Earn
Monthly rates, contract structures, tax considerations and comparison across cruise lines and expedition companies.
Read the guide →Telemedicine at Sea: A Practical Guide for Maritime Clinicians
TMAS frameworks, SBAR-M handovers, satellite communication challenges and legal considerations for remote maritime consultations.
Read the article →Resources
Start With the Essentials
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